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Vesicocutaneous Fistula

A vesicocutaneous fistula (VCF) is a rare abnormal communication between the urinary bladder and the skin surface.[1] Among the least common urinary fistulae, it is most frequently encountered as a consequence of pelvic trauma, prior surgery, radiation therapy, neurogenic-bladder complications, or chronic infection.[2][3][4][5][6]

See also: The Bladder, Fistulas landing page.

Definition and Classification​

A vesicocutaneous fistula is a persistent, epithelialized or granulation-lined tract connecting the bladder lumen to the cutaneous surface.[1] Useful classifications include:

  • Cutaneous opening: suprapubic (most common), inguinoscrotal, perineal, or thigh[2][3][4][7]
  • Etiology: traumatic, iatrogenic, radiation-induced, infectious, or neurogenic-bladder–related
  • Complexity: simple (short, direct tract) vs. complex (long, tortuous, often with associated tissue loss or abscess cavity)

VCF is distinct from other bladder fistulae such as vesicovaginal, vesicouterine, and colovesical fistulae, although the general principles of fistula management overlap.[8][9]

Etiology​

MechanismNotes
Pelvic-fracture bladder injuryMost frequently described mechanism. Extraperitoneal rupture occurs in 60–90% of pelvic fractures with bladder injury; complex extraperitoneal injuries can drive urine extravasation along tissue planes to skin, with delayed presentation up to 7 years post-injury and up to 2 years when presenting as a thigh abscess.[2][4][10][11]
Lower abdominal / pelvic penetrating traumaLoss of skin, fascia, and muscle leaves bladder exposed; closure is difficult without overlying tissue coverage.[3]
Iatrogenic — post-surgicalAfter bladder augmentation, pelvic surgery, or hernia repair. A pediatric VCF after augmentation cystoplasty closed with vacuum-assisted closure (VAC) alone.[1]
Iatrogenic — suprapubic catheter complicationsCatheter displacement, traction on the Foley balloon, or chronic tract issues sustain a fistula around the cystostomy. Long-term indwelling catheters significantly raise the risk of urethral and cutaneous fistulae.[12][13]
Inguinal hernia repairBladder herniation into the inguinal canal (1–4% of inguinal hernias); incarceration with abscess formation can produce VCF presenting as a scrotal abscess.[7]
Radiation therapyPelvic RT for cervical, vulvar, rectal, or prostate cancer; latent period 3 months to 30 years. Endarteritis obliterans → hypoxia → fibrosis → necrosis → fistula. Risk factors: high dose, concurrent chemotherapy, prior surgery, diabetes, and post-radiation biopsies (OR 5.27).[5][14][15][16] A chronic radiation-induced VCF after liposarcoma RT required bipedicled latissimus + serratus anterior free-flap reconstruction.[17]
Neurogenic bladderUnderrecognized cause. In 21 patients with neurogenic-bladder UCF, drivers were decubitus ulcers (33%), wound infection / abscess (24%), condom-catheter complications (19%), traumatic catheterization (19%), and pelvic trauma (5%). Median follow-up 67 months; 81% required permanent urinary diversion.[6]
Infection / inflammatoryPerinephric or pelvic abscess eroding to skin; a remarkable case described a post-infectious intravesical femoral head from septic hip producing VCF as a labial sinus.[18]
MalignancyLocally advanced bladder, colorectal, or other pelvic tumors; a sunitinib-treated unresectable GIST with bladder invasion developed VCF that closed when the anti-angiogenic was discontinued.[19]

Pathogenesis​

Four general factors prevent spontaneous closure of urological fistulae:[20]

  1. Distal obstruction maintaining flow through the tract
  2. Foreign body or calculus physically blocking closure
  3. Granulomatous tissue or malignancy in the tract
  4. Epithelialization of the tract — the fistula develops its own lining

A fifth, particularly relevant to VCF, is radiation-induced ischemia — irradiated tissue has poor vascularity and limited healing capacity.[14][17]

Clinical Presentation​

Presentation is dictated by location and tract size:

  • Continuous or intermittent leakage of urine from the skin — hallmark; clear urine if uninfected, turbid or purulent if infected
  • Skin excoriation and maceration from chronic urine exposure
  • Recurrent perifistular cellulitis or abscess
  • Unusual presentations:
    • Thigh abscess from extravasation tracking along fascial planes years after pelvic trauma[2][4]
    • Scrotal abscess from inguinoscrotal bladder herniation[7]
    • Labial sinus from infected hip joint eroding into bladder[18]
  • Systemic symptoms — fever, malaise, sepsis in complicated cases

Evaluation​

Clinical assessment​

A focused history (prior pelvic trauma, surgery, RT, neurogenic bladder, malignancy) and exam to identify the cutaneous opening and characterize the drainage anchor the workup.

Confirmatory tests​

TestRole
IV indigo carmineSimple bedside confirmation — appearance of blue-stained fluid at the skin opening confirms a urinary source.[2][19]
CT abdomen / pelvis with delayed urographic phase (5–20 min)Primary imaging modality; demonstrates contrast extravasation through the tract and identifies abscess, calculi, malignancy, or bladder deformation.[2][9]
Cystography (retrograde or CT cystography)Gold standard for bladder integrity; CT cystography is more sensitive than plain-film cystography.[11]
CystoscopyDirect visualization of the intravesical opening and assessment of mucosa for malignancy, radiation change, or foreign body
FistulographyContrast injection at the skin opening delineates tract anatomy
MRIUseful for complex / radiation / malignant cases for soft-tissue detail
IVPLargely supplanted by CT urography but can show bladder deformation and the fistula origin.[2]

Management​

General principles​

The same six principles that govern complex enterocutaneous and entero-urinary fistula management apply:[21][22][23][24]

  1. Control of sepsis (drainage of abscess, broad-spectrum antibiotics)
  2. Urinary diversion / decompression to divert urine away from the tract
  3. Skin care and wound management to protect perifistular skin
  4. Nutritional optimization, particularly in complex or post-radiation cases
  5. Treatment of the underlying cause — remove foreign bodies, relieve obstruction, treat malignancy
  6. Definitive surgical repair once the patient is optimized and conservative therapy has failed

Conservative management​

Appropriate for small, uncomplicated fistulae without distal obstruction, foreign body, or malignancy:

  • Continuous bladder drainage with a large-bore (≥ 18 Fr) urethral catheter for a minimum of 7 days, with cystography to confirm healing before removal.[11]
  • Vacuum-assisted closure (VAC) removes excess fluid, reduces edema, promotes granulation, and approximates wound edges. A pediatric VCF after augmentation closed with VAC alone, and VAC has been used as a preoperative bridge before definitive flap reconstruction.[1][25]

Surgical management​

Required for most complex, chronic, or refractory VCF.

  • Fistulectomy with primary bladder closure — excision of the tract followed by two-layer absorbable closure. Standard for simple fistulae with adequate surrounding tissue.[2]
  • Partial cystectomy — when the bladder wall around the fistula is extensively damaged or diseased.[2]
  • Tissue interposition — central principle for complex or recurrent fistulae:
    • Omental flap — most commonly used interposition tissue for abdominopelvic fistulae
    • Muscle flaps — rectus abdominis, gracilis, or rectus femoris musculocutaneous flaps for large defects[25]
    • Free tissue transfer — for the most complex radiation-induced VCF with extensive tissue loss; bipedicled latissimus dorsi + serratus anterior free flap successfully reconstructed both bladder and abdominal wall with no recurrence at 4 months.[17]
  • Layered closure with overlying tissue coverage — for extensive suprapubic post-traumatic VCF, simple bladder closure alone fails; success required muscle and fascial flap coverage in the Bockrath series of two patients.[3]
  • Transurethral suture cystorrhaphy — minimally invasive endoscopic technique reported for selected vesical fistulae, with cystoscopically assisted suture closure of both vesicovaginal and vesicocutaneous fistulae without open surgery.[26]

Neurogenic-bladder VCF​

This population presents unique challenges from chronically elevated bladder pressures, recurrent infection, and impaired healing:[6]

  • Surgical repair was attempted in 13 of 21 patients, but 69% (9/13) eventually required permanent urinary diversion despite repair attempts
  • 8 patients underwent primary urinary diversion at presentation
  • Overall, 81% (17/21) required permanent urinary diversion — suprapubic tube (53%), ileal conduit (23%), condom catheter (18%), or perineal urethrostomy (6%)

Outcomes underscore the importance of addressing the underlying high-pressure neurogenic bladder dysfunction before or concurrent with fistula repair.

Radiation-induced VCF​

The most challenging subset due to poor tissue vascularity:[5][15][17][27][28]

  • Conservative treatment is generally ineffective for established radiation-induced fistulae
  • Tissue interposition with well-vascularized, non-irradiated tissue is essential — local irradiated tissue cannot support healing
  • Free flap reconstruction may be necessary for complex cases[17]
  • Urinary diversion (ileal conduit or continent diversion) may be the most practical option for extensive radiation damage, poor tissue quality, or limited life expectancy
  • Prior radiotherapy is a significant predictor of surgical failure — 75% failure rate in irradiated patients vs. 10.8% in non-irradiated patients (p = 0.012) in a 14-year urogenital fistula series.[27]

Prevention​

  • Prompt recognition and repair of bladder injuries — particularly with pelvic fractures; cystography when bladder injury is suspected.[11]
  • Secure anchoring of suprapubic catheters to prevent traction, displacement, and balloon extrusion.[12]
  • Avoid unnecessary biopsies in irradiated fields — post-radiation biopsies carry an OR of 5.27 for fistula development.[16]
  • Modern image-guided adaptive brachytherapy has reduced the radiation-fistula rate to ~0.7% vs. older techniques.[29]
  • Optimal neurogenic-bladder management — CIC, anticholinergics, and structured urologic follow-up to prevent the chronic high-pressure state that predisposes to fistula formation.[6][13]

Outcomes​

  • Post-traumatic VCF — outcomes scale with extent of tissue loss; simple defects close with layered repair and overlying tissue coverage, while extensive defects may require staged reconstruction.[3]
  • Post-surgical VCF — generally favorable when diagnosed early and managed with diversion ± VAC; spontaneous closure is achievable with adequate decompression.[1]
  • Radiation-induced VCF — worst prognosis among etiologies; 75% surgical failure in irradiated tissue, with permanent diversion often required.[5][17][27]
  • Neurogenic-bladder VCF — 81% require permanent diversion despite repair attempts.[6]
  • Overall — primary success in specialist series ~80.6%, definitive closure ~92.5%. Predictors of failure: prior RT, oncologic etiology, and prolonged delay to repair (12 vs. 6 months, p = 0.027).[27]

References​

1. Elizondo RA, Au JK, Gargollo PC, Tu DT. "Vacuum-Assisted Closure of a Vesicocutaneous Fistula in a Pediatric Patient After Bladder Cystoplasty." Urology. 2016;95:190–191. doi:10.1016/j.urology.2016.04.001

2. Kosaka T, Asano T, Azuma R, et al. "A Case of Vesicocutaneous Fistula to the Thigh." Urology. 2009;73(4):929.e7–8. doi:10.1016/j.urology.2008.04.063

3. Bockrath JM, Nanninga JB, Lewis VL, Grayhack JT. "Extensive Suprapubic Vesicocutaneous Fistula Following Trauma." J Urol. 1981;125(2):246–248. doi:10.1016/s0022-5347(17)54989-7

4. Banihani MN, Al-Azab RS, Waqfi NR, Kharashgah MN, Al Manasra AR. "Vesicocutaneous Fistula Presenting as a Thigh Abscess." Singapore Med J. 2009;50(9):e336–e337.

5. Lau KO, Cheng C. "A Case Report — Delayed Vesicocutaneous Fistula After Radiation Therapy for Advanced Vulvar Cancer." Ann Acad Med Singap. 1998;27(5):705–706.

6. Raup VT, Eswara JR, Weese JR, Potretzke AM, Brandes SB. "Urinary-Cutaneous Fistulae in Patients With Neurogenic Bladder." Urology. 2015;86(6):1222–1226. doi:10.1016/j.urology.2015.07.057

7. Manikandan R, Burke Y, Srirangam SJ, Collins GN. "Vesicocutaneous Fistula: An Unusual Complication of Inguinoscrotal Hernia." Int J Urol. 2003;10(12):667–668. doi:10.1046/j.1442-2042.2003.00715.x

8. Rogers RG, Jeppson PC. "Current Diagnosis and Management of Pelvic Fistulae in Women." Obstet Gynecol. 2016;128(3):635–650. doi:10.1097/AOG.0000000000001519

9. Moon SG, Kim SH, Lee HJ, Moon MH, Myung JS. "Pelvic Fistulas Complicating Pelvic Surgery or Diseases: Spectrum of Imaging Findings." Korean J Radiol. 2001;2(2):97–104. doi:10.3348/kjr.2001.2.2.97

10. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and Uro-Trauma: WSES-AAST Guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x

11. Johnsen N, Wessells H, Archer-Arroyo K, et al. "Best Practices Guidelines: Management of Genitourinary Injuries." American College of Surgeons. 2025.

12. Vaidyanathan S, Hughes PL, Soni BM. "Unusual Complication of Suprapubic Cystostomy in a Male Patient With Tetraplegia: Traction on Foley Catheter Leading to Extrusion of Foley Balloon From Urinary Bladder and Suprapubic Urinary Fistula." ScientificWorldJournal. 2007;7:1575–1578. doi:10.1100/tsw.2007.253

13. Utomo E, Groen J, Blok BF. "Surgical Management of Functional Bladder Outlet Obstruction in Adults With Neurogenic Bladder Dysfunction." Cochrane Database Syst Rev. 2014;(5):CD004927. doi:10.1002/14651858.CD004927.pub4

14. Denton AS, Clarke NW, Maher EJ. "Non-Surgical Interventions for Late Radiation Cystitis in Patients Who Have Received Radical Radiotherapy to the Pelvis." Cochrane Database Syst Rev. 2002;(3):CD001773. doi:10.1002/14651858.CD001773

15. Turina M, Mulhall AM, Mahid SS, Yashar C, Galandiuk S. "Frequency and Surgical Management of Chronic Complications Related to Pelvic Radiation." Arch Surg. 2008;143(1):46–52; discussion 52. doi:10.1001/archsurg.2007.7

16. Feddock J, Randall M, Kudrimoti M, et al. "Impact of Post-Radiation Biopsies on Development of Fistulae in Patients With Cervical Cancer." Gynecol Oncol. 2014;133(2):263–267. doi:10.1016/j.ygyno.2014.02.005

17. Ludolph I, Apel H, Horch RE, Beier JP. "Treatment of a Chronic Vesicocutaneous Fistula and Abdominal Wall Defect After Resection of a Soft Tissue Sarcoma Using a Bipedicled Latissimus Dorsi and Serratus Anterior Free Flap." Int J Urol. 2014;21(11):1178–1180. doi:10.1111/iju.12545

18. Jain V, Sen B, Jain P, et al. "Postinfection Intravesical Femoral Head Resulting in a Vesicocutaneous Fistula: A Bizarre Presentation and Outcome." Pediatr Infect Dis J. 2006;25(10):954–955. doi:10.1097/01.inf.0000237923.61105.1a

19. Watanabe K, Otsu S, Morinaga R, et al. "Vesicocutaneous Fistula Formation During Treatment With Sunitinib Malate: Case Report." BMC Gastroenterol. 2010;10:128. doi:10.1186/1471-230X-10-128

20. Jones J, Aboumarzouk OM. "Fistulae and Sinuses." Chapter 24.

21. Pepe G, Chiarello MM, Bianchi V, et al. "Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights Into Management Using Negative Pressure Wound Therapy." J Clin Med. 2024;13(5):1279. doi:10.3390/jcm13051279

22. Shackley DC, Brew CJ, Bryden AA, et al. "The Staged Management of Complex Entero-Urinary Fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

23. Gill HS. "Diagnosis and Surgical Management of Uroenteric Fistula." Surg Clin North Am. 2016;96(3):583–592. doi:10.1016/j.suc.2016.02.012

24. Kumpf VJ, de Aguilar-Nascimento JE, Diaz-Pizarro Graf JI, et al. "ASPEN-FELANPE Clinical Guidelines." JPEN J Parenter Enteral Nutr. 2017;41(1):104–112. doi:10.1177/0148607116680792

25. Katsuragi Y, Ueda K, Kajikawa A, Tateshita T, Okochi H. "Repair of a Huge Vesicocutaneous Fistula With the Rectus Femoris Musculocutaneous Flap and VAC." J Wound Care. 2010;19(4):157–159. doi:10.12968/jowc.2010.19.4.157

26. McKay HA. "Vesicovaginal and Vesicocutaneous Fistulas: Transurethral Suture Cystorrhaphy as a New Closure Technique." J Urol. 1997;158(4):1513–1516. doi:10.1016/s0022-5347(01)64256-3

27. Zhang C, Saussine C, Tricard T. "Urogenital Fistulas: Surgical Management, Outcomes, and Prognostic Factors: A 14-Year Monocentric Experience." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06580-0

28. Angioli R, Penalver M, Muzii L, et al. "Guidelines of How to Manage Vesicovaginal Fistula." Crit Rev Oncol Hematol. 2003;48(3):295–304. doi:10.1016/s1040-8428(03)00123-9

29. Okada Y, Matsushita T, Hasegawa T, et al. "Surgical Interventions for Treating Vesicovaginal Fistula in Women." Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413